Advances in Perineal Reconstruction After Abdominoperineal Resection: A Narrative Review of Techniques, Algorithms, and Future Directions

Document Type : Review Article

Authors

1 Department of Surgery, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran

2 Equal contributions and should be recognized as co-first authors.

3 Department of Gynecology and Obstetrics, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran

4 Razi Clinical Research Development Unit, Razi Hospital, Mazandaran University of Medical Science, Sari, Iran

5 Clinical Research Development Unit of Imam Khomeini Hospital, Mazandaran University of Medical Science, Sari, Iran

10.30476/acrr.2026.108545.1261

Abstract

Advances in rectal cancer treatment in the modern medical era have brought increased attention to wound complications, quality of life, and the recovery process. Consequently, perineal wound complications have become a significant concern following abdominoperineal resection (APR) for rectal and anal malignancies, especially in cases involving irradiation or anatomically complex surgical fields. This narrative review aims to review treatment options and various reconstructive strategies to optimize wound healing and functional outcomes. These options include primary closure, rotational and transposition flaps, musculocutaneous and perforator flaps, mesh prostheses, and emerging tissue-engineered scaffolds. Each method is critically evaluated with respect to indications, complication rates, and long-term outcomes, with comparative data guiding evidence-based selection.
To provide a comprehensive overview and improve the practical application of this review, we propose several algorithms designed to facilitate individualized surgical planning by incorporating patient-specific factors, defect characteristics, and oncologic context. These approaches are discussed within the framework of enhanced recovery protocols, highlighting the importance of multidisciplinary collaboration in achieving optimal outcomes.

Highlights

Mina Alvandipour(Google Scholar)

Mohammad Javad Najafi(Google Scholar)

Keywords

References

  1. Siegel RL, Wagle NS, Cercek A, et
    al. Colorectal cancer statistics, 2023.
    CA: a cancer journal for clinicians.
    2023 May;73(3):233-54.
    2. Chang CC, Lan YT, Jiang JK, et al.
    Risk factors for delayed perineal
    wound healing and its impact
    on prolonged hospital stay after
    abdominoperineal resection. World
    journal of surgical oncology. 2019 Dec
    21;17(1):226.
    3. Buscail E, Canivet C, Shourick J, et
    al. Perineal wound closure following
    abdominoperineal resection and
    pelvic exenteration for cancer: a
    systematic review and meta-analysis.
    Cancers. 2021 Feb 10;13(4):721.
    4. Gambardella C, Mongardini FM,
    Karpathiotakis M, et al. Biosynthetic
    mesh reconstruction after
    abdominoperineal resection for low
    rectal cancer: cross relation of surgical
    healing and oncological outcomes:
    a multicentric observational study.
    Cancers. 2023 May 11;15(10):2725.
    5. Gendia A, Rehman M, Lin CW, et
    al. Short-and mid-term outcomes
    of abdominoperineal resection with
    perineal mesh insertion: a singlecentre
    experience. International
    Journal of Colorectal Disease. 2023
    Aug 22;38(1):220.
    6. Sharabiany S, Brouwer TP, Kreisel
    SI, et al. Mesh, flap or combined
    repair of perineal hernia after
    abdominoperineal resection–A
    systematic review and metaanalysis.
    Colorectal Disease. 2022
    Nov;24(11):1285-94.
    7. Temperley HC, Shokuhi P,
    O’Sullivan NJ, et al. Primary closure
    versus vertical rectus abdominis
    myocutaneous (VRAM) f lap
    closure of perineal wound following
    abdominoperineal resection—a
    systematic review and meta-analysis.
    Irish Journal of Medical Science
    (1971-). 2024 Aug;193(4):1721-8.8. Irani JL, Hedrick TL, Miller TE, et
    al. Clinical practice guidelines for
    enhanced recovery after colon and
    rectal surgery from the American
    Society of Colon and Rectal Surgeons
    and the Society of American
    Gastrointestinal and Endoscopic
    Surgeons. Diseases of the Colon &
    Rectum. 2023 Jan 1;66(1):15-40.
    9. Kalev G, Buettner S, El-Ahmar M,
    et al. Reconstruction of the perineal
    defect after abdominoperineal
    resection with vertical rectus
    abdominis myocutaneous (VRAM)
    flap versus primary direct closure-a
    single center retrospective cohort
    study. Langenbeck’s Archives of
    Surgery. 2025 Jul 9;410(1):217.
    10. Moraru DC, Pertea M, Luca S, et al.
    Personalized Decisional Algorithms
    for Soft Tissue Defect Reconstruction
    after Abdominoperineal Resection for
    Low-Lying Rectal Cancers. Current
    Oncology. 2024 Jun 4;31(6):3253-68.
    11. Niranjan NS, Fox P, Mittermiller
    P, et al. Genitourinary and perineal
    reconstruction. Plastic and
    reconstructive surgery: Approaches
    and techniques. 2015 Apr 21:575-96.
    12. Alvandipour M, Sayyadi S,
    Samarghandi N, et al. Impact of
    Limberg Flap Reconstruction
    Following Abdominoperineal
    Resection: A Randomized Controlled
    Trial. Journal of Gastrointestinal
    Cancer. 2025 Dec;56(1):163.
    13. Hainsworth A, Al Akash M, Roblin
    P, et al. Perineal reconstruction after
    abdominoperineal excision using
    inferior gluteal artery perforator
    flaps. Journal of British Surgery. 2012
    Apr;99(4):584-8.
    14. Harries RL, Radwan RW, Dewi
    M, et al. Outcomes following
    immediate vertical rectus abdominis
    myocutaneous (VRAM) flap‐based
    perineal reconstruction following
    resectional surgery for pelvic
    malignancies. World Journal of
    Surgery. 2021 Jul;45(7):2290-7.
    15. Faur IF, Clim A, Dobrescu A,
    et al. VRAM flap for pelvic
    floor reconstruction after pelvic
    exenteration and abdominoperineal
    excision. Journal of Personalized
    Medicine. 2023 Dec 14;13(12):1711.
    16. Radwan RW, Tang AM, Harries RL,
    et al. Vertical rectus abdominis flap
    (VRAM) for perineal reconstruction
    following pelvic surgery: a
    systematic review. Journal of Plastic,
    Reconstructive & Aesthetic Surgery.
    2021 Mar 1;74(3):523-9.
    17. Sagebiel TL, Faria SC, Balachandran
    A, et al. Pelvic reconstruction
    with omental and VRAM flaps:
    anatomy, surgical technique,
    normal postoperative findings, and
    complications. Radiographics. 2011
    Nov;31(7):2005-19.
    18. Eseme EA, Scampa M, Viscardi
    JA, et al. Surgical outcomes of
    Vram vs. Gracilis Flaps in vulvoperineal
    reconstruction following
    oncologic resection: A proportional
    meta-analysis. Cancers. 2022 Sep
    1;14(17):4300.
    19. Fielding A, Kulkarni S, Kapur S, et al.
    Perineal reconstruction after complex
    pelvic anorectal surgery with the
    pedicled gracilis flap: a single-centre
    retrospective cohort study. European
    Journal of Plastic Surgery. 2025 May
    17;48(1):44.
    20. Shahzad F, Ray E. Pelvic and
    perineal reconstruction. Plastic and
    reconstructive surgery. 2024 Oct
    1;154(4):803e-16e.
    21. Thiele JR, Weber J, Neeff HP, et al.
    Reconstruction of perineal defects:
    a comparison of the myocutaneous
    gracilis and the gluteal fold flap in
    interdisciplinary anorectal tumor
    resection. Frontiers in Oncology. 2020
    May 6;10:668.
    22. Fr a n c o n e T. R o b o t i c
    Abdominoperineal Resection (APR)
    with Bilateral Gracilis Muscle Flaps.
    Journal of Medical Insight. 2025 Feb
    5;2025(1).
    23. Anderin C, Martling A, Lagergren
    J,et al. Short‐term outcome after
    gluteus maximus myocutaneous
    flap reconstruction of the pelvic
    f loor following extra‐levator
    abdominoperineal excision of the
    rectum. Colorectal disease. 2012
    Sep;14(9):1060-4.
    24. Davison E, Allan AY, Kang N. The
    use of gluteus maximus to restore
    the function of the pelvic diaphragm
    in the reconstruction of the pelvic
    outlet after abdomino-perineal
    resection: a case series. European
    Journal of Plastic Surgery. 2023
    Dec;46(6):1219-25.
    25. Unal C, Yirmibesoglu OA,
    Ozdemir J, et al. Superior and
    inferior gluteal artery perforator
    flaps in reconstruction of gluteal
    and perianal/perineal hidradenitis
    suppurativa lesions. Microsurgery.
    2011 Oct;31(7):539-44.
    26. Sharabiany S, Blok RD, Lapid O, et al.
    Perineal wound closure using gluteal
    turnover flap or primary closure
    after abdominoperineal resection
    for rectal cancer: study protocol of
    a randomised controlled multicentre
    trial (BIOPEX-2 study). BMC surgery.
    2020 Jul 23;20(1):164.
    27. Faucheron JL, Foote A, Tidadini
    F. Perineal Wound Closure Using
    Gluteal Turnover Flap. JAMA
    surgery. 2025 Sep 1;160(9):1038-9.
    28. Manjunath KN, Waiker PV,
    Shanthakumar S, et al. Efficacy of
    pedicled anterolateral thigh flap for
    reconstruction of regional defects-a
    record analysis. Acta Chir Plast. 2022
    Jan 1;64(1):6-11.
    29. Duan A, Xiang Z, Fan Y, et al.
    Evaluating the clinical efficacy of the
    anterolateral thigh flap in lower limb
    reconstruction surgeries: a systematic
    review and meta-analysis. American
    journal of translational research. 2024
    Jul 15;16(7):3326.
    30. Hsu CC, Loh CY, Wei FC. The
    anterolateral thigh perforator flap:
    its expanding role in lower extremity
    reconstruction. Clinics in Plastic
    Surgery. 2021 Apr 1;48(2):235-48.
    31. Sagebiel TL, Faria SC, Balachandran
    A, et al. Pelvic reconstruction with
    pedicled thigh flaps: indications,
    surgical techniques, and
    postoperative imaging. American
    Journal of Roentgenology. 2014
    Mar;202(3):593-601.
    32. Algan S, Tan O. Profunda femoris
    artery perforator flaps: a detailed
    anatomical study. Journal of Plastic
    Surgery and Hand Surgery. 2020 Dec
    1;54(6):377-81.
    33. Ciudad P, Kaciulyte J, Torto FL, et
    al. The profunda artery perforator
    free flap for lower extremity
    reconstruction. Microsurgery. 2022
    Jan;42(1):13-21.
    34. Hupkens P, Ozturk E, Wittens S, et
    al. Posterior thigh perforator flaps:
    an anatomical study to localize and
    classify posterior thigh perforators.
    Microsurgery. 2013 Jul;33(5):376-82.
    35. Alam NN, Narang SK, Köckerling F,
    et al. Biologic mesh reconstruction
    of the pelvic floor after extralevator
    abdominoperineal excision: a
    systematic review. Frontiers in
    surgery. 2016 Feb 16;3:9.
    36. Sun J, Chen C, Zhang B, et al.
    Advances in 3D-printed scaffold
    technologies for bone defect repair:
    materials, biomechanics, and clinical
    prospects. BioMedical Engineering
    OnLine. 2025 Apr 30;24(1):51.
    37. Liu N, Zhang X, Guo Q, et al.
    3D bioprinted scaffolds for tissue
    repair and regeneration. Frontiers in
    Materials. 2022 Jul 7;9:925321.
    38. Vyas J, Raytthatha N, Vyas P, et al. Biomaterial-Based Additive
    Manufactured Composite/Scaffolds for
    Tissue Engineering and Regenerative
    Medicine: A Comprehensive Review.
    Polymers. 2025 Apr 17;17(8):1090.
    39. Chen G, Ushida T, Tateishi T.
    Scaffold design for tissue engineering.
    Macromolecular Bioscience. 2002 Feb
    1;2(2):67-77.
    40. Chen H, Song G, Xu T, et al.
    Biomaterial scaffolds for periodontal
    tissue engineering. Journal of
    Functional Biomaterials. 2024 Aug
    20;15(8):233.
    41. Li R, Zhao Y, Zheng Z, et al. Bioinks
    adapted for in situ bioprinting
    scenarios of defect sites: a review.
    RSC advances. 2023;13(11):7153-67.
    42. Andrew TW, Coyne P, Alrawi M.
    Perineal reconstruction algorithm
    for recurrent lower rectal and anal
    carcinoma. European Journal of
    Plastic Surgery. 2023 Feb;46(1):85-93.
    43. Bercz A, Alvarez J, Rosen R, et
    al. Assessment of morbidity and
    predictors of wound complications
    following perineal wound closure
    after radical anorectal oncologic
    resection: retrospective cohort study.
    BJS open. 2025 Jun;9(3):zraf065.
Iranian Journal of Colorectal Research
Volume 13, Issue 3
September 2025

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